Counting the Cost of Choice and Control: Evidence for the costs of self-directed support in Scotland

EXECUTIVE SUMMARY

Introduction

1. Self-directed support (SDS) allows people needing social care services to exercise greater choice and control over how they receive services and support.

2. The Scottish Government aims to introduce legislation in 2012 (the Social Care (Self Directed Support) (Scotland) Bill) which will consolidate existing (sometimes complex) provision for SDS. It is intended to bring SDS into the mainstream of social care and increase the numbers of people directing their own support.

3. Under the forthcoming bill, Local Authorities will be placed under a duty to offer service users a variety of options which include:

• Direct Payments (DPs) - the making of a payment directly to service users to arrange their own support;
• Directing the available resource - where the user selects the support that they wish and the Local Authority arranges matters on their behalf. In practice this would encompass options such as Individual Service Funds (ISFs) where the Local Authority contracts with providers on behalf of the service user;
• Local Authority 'arranged' support where the authority arranges support on the user's behalf to meet their needs; and
• A mix of the above options for distinct aspects of the user's support.

4. This study was commissioned to provide inform the SDS strategy and to provide evidence for the forthcoming SDS bill on the current and future costs of SDS in Scotland in order to understand the resource implications of making SDS mainstream and increasing the numbers of people directing their own support.

Background

5. Recent years have seen a growing emphasis in Scotland on developing social care services that allow service users greater choice and control, whilst being as cost effective as possible. Developments such as the use of Direct Payments (DPs) - where users can purchase their own services (for example by employing a personal assistant (PA) rather than receiving home care services) - have been demonstrated to offer some users more control and better outcomes (including improved health and social wellbeing, the ability to combine health and social care support, and to combine formal and informal care more effectively, as well as greater independence and control over services, and more cost-effective delivery of services).

6. However, the take-up of DPs in Scotland has been variable, and the option of directly purchasing their own services is not the only way that users can gain the benefits associated with greater choice and control over their services. Some of the barriers to the take-up of DPs included lack of awareness from front-line workers and managers, and the need to invest in advocacy and support organisations to help users manage their payments, as well as concerns expressed about the risks involved for vulnerable users and a resistance to the perceived 'privatisation' of social care. Self-directed support (SDS) offers a range of options giving service users increased control over more personalised services.

7. The Scottish Government has commissioned several studies to contribute towards an understanding of the factors which determine the uptake and impact of SDS. These studies have informed both the SDS Strategy (Scottish Government, 2010) and the SDS Bill. These studies have included an evaluation of three SDS test sites in Scotland (Ridley et al, 2011) which were set up to assess the impacts of three types of intervention (bridging finance, cutting red tape and leadership and training).

Aims of study

8. The overall aim of this study was to provide macro-level financial and economic evidence on the potential costs, benefits and impacts of an increase in the uptake of SDS in Scotland.

9. The first specific objective was to describe the baseline in three Local Authorities, looking at the current operation of SDS, the number and profile of SDS clients and type of SDS accessed, to assess the current costs of providing SDS for providers, and to determine the financial and socio-economic impact of the move to SDS, including the resources needed to facilitate a shift towards higher levels of SDS and to compare this to the previous spend on social care.

10. The second specific objective was to consider the future and to estimate the ongoing and future costs resulting from the predicted shift to more SDS, and to assess the sustainability of this shift. It was also to estimate how further changes in SDS resulting from the forthcoming legislation may impact on Local Authorities, service providers, SDS users and family carers and to consider the external validity and reliability of the results.

Methods

11. Three Local Authorities who had a high number of DP users across several user groups were and the availability and accessibility of data was confirmed.

12. A range of methods were used to carry out the study:

• a reference group of SDS users, carers and advisors who were not based in the sample Local Authorities were appointed to provide assistance in the design of the costing methodology, and to check the external validity and reliability of findings.
• Data on overhead costs associated with DPs¹ including costs of central services, transport and accommodation was collected via meetings and structured interviews with a range of Local Authority officers (n=14).
• Information from a service provider with experience of providing services across several local authorities was gathered through a focus group (8 participants).
• Interviews with service providers in the private and third sectors providing services in different geographical areas and for different user groups (8 participants).
• A group interview with representatives of a DP support organisation (2 participants).
• Anonymised, matched samples of DP users and users of standard services, stratified in terms of disability type were provided by the three Local Authorities (265 usable records).
• A postal survey sent to 210 DP users. A total of 59 responses were received.
• Desk based analysis was used to simulate different rates of increase in SDS provision and to estimate future demand and costs using information from the user survey and qualitative elements of this study and information on the prevalence of various types of disability and population estimates by Local Authority from GROS.

Main issues for Local Authorities

13. The research found that the full costs of providing SDS were difficult to measure and predict. However, the experience of DPs showed that it was possible to develop transparent costings systems for individual users.

14. There were significant variations in costs, and the way these were calculated, across different user groups and different Local Authorities. More transparency about service costs may make things fairer: however, they may also expose inequities across different groups and locations that are not easy to address.

15. Evidence suggests that Commissioners, such as Local Authorities, are likely to continue to play an important role in safeguarding the quality and cost of care services. However, individual SDS users will be able to exercise their choice about service provision, and move contracts more quickly than Local Authorities.

16. Initially, the research indicated that the resources needed for SDS assessments and monitoring may increase, but these costs were considered likely to decrease over time as SDS becomes more mainstream and systems develop. There was no evidence to suggest that the resources and costs associated with SDS will be significantly greater than those associated with managing the provision of social care generally.

Main issues for service providers

17. There was broad support for the aims of SDS, particularly around the increased empowerment, choice and control offered to users. However, there were also concerns about the costs of providing flexible services, particularly the risk of investing in staff training and infrastructure if services are destabilised (e.g. by SDS users changing contracts at short notice).

18. Variations in pricing and the demand for services may make it difficult for some providers to effectively plan and deliver services.

19. There was a perceived danger of a 'two tier' care workforce emerging, with (relatively unregulated, relatively unprotected and therefore cheaper) PAs on the one hand, and (more regulated, more protected and therefore more expensive) workers for care agencies and Local Authorities on the other.

20. New possibilities and new markets may open up for providers with the expansion of SDS, particularly those able to provide high quality, responsive and flexible services, and additional support for training, advocacy and advice.

Main issues for SDS users and family carers

21. Although it is difficult to predict what these will be, the research indicated that some of the costs of the increased flexibility of SDS will fall on users and family carers. Some of these risks may be offset if Local Authorities invest in independent advocacy and support organisations, to give users and family carers support in managing SDS.

22. DP users were overwhelmingly positive about the increased choice and control offered by DPs and SDS. The benefits of increased empowerment and flexibility were also felt by family carers.

23. There was concern expressed that users and carers may find the complexity of SDS difficult to manage without sufficient support.

Future trends

24. Our research indicates that the relationship between an individual user's needs and the costs of the support they receive is not clear: higher needs do not necessarily mean costlier services. DP users are most likely to purchase services from a PA, and least likely to purchase Local Authority services. We predict that this pattern will continue under SDS.

25. There were no significant difference in the hours of care between DP users and those who received Local Authority social care services. This suggests that a move to SDS will not result in a reduction in services, and that costs do not differ significantly between DPs and Local Authority social services. We conclude that fears about reduced services and increased costs associated with SDS are therefore unfounded: personalisation and SDS do not, per se, lead to reduced services and support.

26. However, as SDS becomes mainstream, there are likely to be concerns about the market for care services if costs are driven up by new contractual forms, or by more SDS users opting to employ PAs rather than use services.

27. Our research and modelling indicates that the costs of care will increase in the next 10 years: however, these rising costs are due to rising levels of need for social care services in the population and are not specific to SDS.

28. Our predictions on the costs of SDS are sensitive to the rate of expansion - e.g. the costs of employing PAs compared to 'in-house' (public, private or voluntary sector) carers. If these costs change, or if the types of choices SDS users make deviate significantly from the way they have used DPs in the past, our conclusions are likely to be less robust.

Conclusions

29. The expansion of SDS in Scotland is not uncontentious. The aspirations for improved empowerment, choice and control which drive the policy are broadly supported by all the stakeholders involved in this project. However, it is not yet clear that SDS can deliver all it promises, particularly in the era of resource constraints and significant pressures on social care budgets. This project has highlighted significant concerns about the variations in costs across Local Authorities and different user groups, and uncertainties about equity and fairness in delivering high quality, cost-effective social care services to individual users. There are concerns about where costs will fall, and what the impact of SDS will be on different sectors. Implementing SDS policy will require, to a certain extent, a 'leap of faith' for Local Authorities.

30. However, there is no evidence to suggest that SDS is more costly than other options for delivering social care services. Given the potential for increased empowerment, choice and control for users and family carers, that 'leap of faith' will, hopefully, prove justified.